Intrigued at what the incidence of VAD was from spinal manipulation specifically, Jack went back to his default search engine. A few seconds later, he was scanning through a plethora of articles. He quickly found an article he thought promising and clicked on it. As he read it, he found it far more disturbing than the first as it was a systematic review of thirty-five actual cases of strokes caused by cervical spine manipulation that had been reported in the medical literature from 1995 to 2001. The vast majority involved chiropractors, and most of the lesions were vertebral artery dissections. Outcomes varied from full recovery in six percent of patients to varying levels of permanent neurological deficits or death in the remaining ninety-four percent. One of the listed patients who had died was a three-month-old baby girl.
Jack leaned back and stared up at the ceiling. What malady would lead parents to think an infant’s symptoms would be relieved by cervical neck manipulation, suddenly and forcibly twisting the infant’s neck beyond a point of normal resistance? And what had gone through the supposed therapist’s mind that gave him or her the audacity to do such a thing? Jack wasn’t just horrified—he was angry.
Moving on to the discussion section of the article, Jack read that there was evidence that the thirty-five cases discussed were only a small portion of such cases, since underreporting was apparently widespread. To back up this statement a survey of physician specialists at a meeting of the Stroke Council of the American Heart Association reported three hundred sixty unreported cases of stroke after spinal manipulations! How could this be? Jack questioned.
Placing his hands on either side of his head, Jack shook it in disbelief, questioning why this issue was not more commonly known. After puzzling over the situation for a few minutes and coming to no conclusion, Jack returned his attention to Keara Abelard’s case.
He angrily riffled through the mass of papers on his desk until he located the telephone number of Keara’s friend who’d allegedly recommended chiropractic. He dialed, then tried to calm himself as the call went through. He knew it could be counterproductive to intimidate Keara’s friend. When she answered, Jack identified himself and mentioned his official title in as poised a manner as he was capable. His introduction was greeted with silence.
“Are you still there?” Jack inquired. “You are Nichelle Barlow, aren’t you?”
“Are you calling from the morgue?” the woman asked, with obvious concern.
“I am. Are you Nichelle Barlow?”
“Yes,” she replied reluctantly, apparently trying to prepare herself for what couldn’t be good news.
“I got your number from Mrs. Abelard. I hope I’m not disturbing you.”
“It’s okay,” she said hesitantly. “Are you calling me about Keara?”
“I am. I suppose you weren’t out with her and her friends last night.”
“No, I wasn’t, but don’t tell me she . . .” Nichelle said but was unable to complete the sentence.
“Unfortunately, Keara passed away last night,” Jack said. “I’m sorry to be the bearer of bad news.”
“What happened?”
“She had a stroke.”
“A stroke?” Nichelle said with disbelief. “Keara was my age, only twenty-seven.”
“Strokes are more common the older one gets, but even children can have them.”
“I can’t believe this. Is this some kind of sick prank?”
“I’m afraid not, Ms. Barlow,” Jack said calmly. “The reason I’m calling is because I’m investigating your friend’s death. Any sudden passing of an individual in apparent good health and with no known cause falls under the jurisdiction of the medical examiner’s office. What I need is some information. You were aware that Keara was suffering from headaches?”
“That’s what she said. But I didn’t get the impression they were particularly bad. More nuisance than debilitating.”
“Did she describe them to you?”
“Sort of. She said they were behind her eyes, more on the right than the left. She said she gets them when she is under stress, and with her new job she said she was under a lot of stress.”
“Her mother told me you had suggested she see a chiropractor.” Jack kept his voice neutral to avoid casting blame.
“She said ibuprofen wasn’t helping, so I suggested my chiropractor.”
“Did she take your advice?”
“It sounded like she was going to, but I don’t know for sure. The last time I spoke with her was last Wednesday.”
“What is this chiropractor’s name?”
“Dr. Ronald Newhouse. He’s a wonderful doctor.”
“When you say ‘doctor,’ you are aware he’s not a medical doctor?”
“He’s a doctor, he just can’t do surgery or prescribe drugs.”
Jack felt his anger seeping back, but he fought against it. He wasn’t going to be able to change Nichelle’s ideas about this, but he couldn’t let her misconception go completely unchallenged. “Your chiropractor calls himself a doctor, but he is a doctor of chiropractic, not a doctor of medicine. Can you tell me where Dr. Newhouse has his office?”
“Fifth Avenue between Sixty-fourth and Sixty-fifth. Hold on and I’ll get you the telephone number.”
In a moment Nichelle came back on the line. After she gave Jack the number, he asked, “How long have you been a patient of his?”
“About eight years. He’s been my savior. I see him for almost everything.”
“What do you see him for specifically?”
“Whatever ails me: sinusitis, mostly. That and gastric reflux. I’d be a wreck if it weren’t for Dr. Newhouse.”
“Ms. Barlow,” Jack began, then paused. For a moment he mulled over what he wanted to say. “I’m curious to know how your chiropractor treats your sinusitis.”
“He adjusts me. Usually he works on my cervical vertebrae, but sometimes my lumbar. I’ve got one hip higher than the other, and my back is a mess, but it’s definitely getting better. You should see the changes in my X-rays. It’s remarkable.”
“Does he take spine X-rays often?” Jack asked, horrified at the thought. The radiation required for spinal radiology was significant.
“Most every visit,” Nichelle said proudly, as if she thought the more X-rays, the better. “He’s a very, very thorough doctor. The best that I’ve ever been to, truly.”
Jack cringed at this inappropriate glowing assessment of someone who was treating sinusitis undoubtedly caused by an overgrowth of bacteria with potentially dangerous cervical manipulation and unneccessary radiation to boot! Even if the machine was digital, over time the dose would add up.
“Thank you for your help, Ms. Barlow,” Jack said, making an effort to avoid the temptation to contradict the woman. The fact that a seemingly intelligent and educated person could hold such off-the-wall opinions in this day and age was a mystery to him. But he didn’t dwell on it.
Jack disconnected rather abruptly. He knew that had he not done so, he surely would have ended up lecturing Nichelle about her need to apply a modicum of her intelligence to her health-care choices. She was admittedly using her chiropractor as a GP. Without even replacing the handset, he began dialing Ronald Newhouse’s office. At about the halfway point he stopped, paused, then put the receiver it its cradle. He still felt enraged, and in that state of mind he was prescient enough to know he couldn’t have a coherent conversation. The idea that the man truly believed he could treat a sinus infection with spinal adjustment was execrable. The man had to be a charlatan.
To calm himself, Jack turned to composing an e-mail asking the thirty-plus other New York City medical examiners if they’d had any cases of VAD, particularly chiropractor-induced VAD. He was about to send the message when he decided to expand the request to deaths involving all types of alternative medical therapy, including but not limited to homeopathy, acupuncture, and Chinese herbal medicine.
Jack then searched the Barnes & Noble website for alternative-medicine titles and was amazed at the number av
ailable. Reading through the descriptions, he noted that there seemed to be many more pro than con, despite what he felt was the shaky underpinning of the various therapies. This only added to his curiosity, especially in an era when conventional medicine was moving toward more evidence-based therapy.
One title struck him: Trick or Treatment. He called one of the Barnes & Nobles on the West Side and asked that a copy be put aside. He was motivated to rectify his shameful ignorance of the subject.
Feeling more like himself, Jack went back to telephoning Ronald Newhouse. Again, halfway through the dialing process, he stopped and hung up the phone. He suddenly decided a site visit was in order, even though he knew very well that the powers-that-be frowned on site visits by the MEs. The OCME protocol called for site visits to be made by the well-trained medicolegal team, not medical examiners, unless extraordinary circumstances demanded the presence of a trained forensic pathologist. Although Jack guessed that neither the deputy chief nor the chief would see the current situation as one of those “extraordinary circumstances,” he decided to do it anyway. He had an irresistible urge to look the chiropractor in the eyes while he explained how spinal manipulation could cure sinusitis. He also wanted to see his expression when he told the guy he’d killed Keara Abelard, treating her for a garden-variety tension headache.
It had been a while since he last made a site visit. Back when he was newly hired, especially when he was involved in a complicated infectious-disease case, he made a lot of them, and almost got himself fired several times. The chief, Dr. Harold Bingham, had come within inches of dismissing Jack for willful insubordination.
As he waited for the elevator, Jack realized that if Ronald Newhouse had treated Keara with the suspected cervical manipulation, Jack wasn’t required to put “therapeutic complication” as the manner of death on the death certificate, which would be what everyone from Bingham on down would expect. He didn’t even have to put “accidental,” which was the designation for such a case before “therapeutic complication” had been devised in the mid-nineties. Jack realized he could put “homicide” as the cause of death, then turn the case report over to the DA as was done in more typical cases of criminality. “What a stir that would cause,” Jack said to himself with a mischievous smile as he boarded the elevator. And thinking in that vein, he thought that perhaps such a “political bomb” was what was needed to draw attention to the dangers of cervical manipulation.
9
12:55 P.M., MONDAY, DECEMBER 1, 2008
NEW YORK CITY
(7:55 P.M., CAIRO, EGYPT)
By the time Jack braked to a stop in front of Ronald Newhouse’s Fifth Avenue office, he felt better than he had in months. He was motivated, thanks to Keara Abelard, by having stumbled on the perfect diversion: a crusade of exposing the dangers of alternative medicine. He couldn’t wait to come face-to-face with the man.
Jack hopped off his bike and went about applying the collection of locks he used to secure his Trek. As he was applying the last one, someone tapped him on the shoulder.
Jack looked up into the face of a uniformed doorman, looking like he stepped off a movie set in his old-fashioned greatcoat with two rows of shiny brass buttons. “Sorry,” he said in a tone that suggested he wasn’t sorry at all. “You can’t leave your bike here. It’s against the rules.”
Redirecting his attention to the final lock, Jack finished the task of securing the bike.
“Hey, buddy!” the doorman said. “Did you hear me? You can’t leave the freaking bike here. It’s private property.”
Standing up without saying a word, Jack fished in his pants pocket, pulled out his wallet, and flashed his official New York City medical examiner’s badge. It looked to all the world like a policeman’s badge, unless you looked closely.
“Sorry, sir!” the doorman said hastily.
“It’s quite all right,” Jack said. “The bike won’t be here long.”
“No problem, sir. I’ll keep my eye on it. Can I help you in any way?”
“I’m here to see Ronald Newhouse,” Jack said. He couldn’t bring himself to use the title “doctor.” Nor did he say whether he was there in an official capacity or as a patient.
“This way, sir,” the doorman said obsequiously, gesturing toward the front door and leading Jack into the foyer. He opened the inner door with a key and pointed. “Dr. Newhouse’s office is down the hall, first door on the left.”
“Thank you,” Jack said, wondering if the man would have been equally gracious if he knew Jack was a medical examiner.
DR. RONALD NEWHOUSE AND ASSOCIATES was stenciled in gold leaf on the door. When he walked in, it was immediately apparent that Newhouse ran a successful practice. Not only could he afford the Fifth Avenue rent, which Jack assumed was significant, he’d had the waiting room decked out in style. There were original oil paintings on the walls, plush furniture, and a large Oriental rug. What made it appear different from any successful medical doctor’s office he’d seen were three stools with contour seats connected to their bases by a movable ball joint. A woman in her twenties occupied one of the stools. With her hands on her knees and her legs spread apart such that her dress drooped between her knees, she was in constant motion in a manner that reminded Jack of his daughters using their hula hoops. While he watched her, the woman caught his eye and smiled. She appeared completely unself-conscious, leading Jack to believe the unique activity was normal in the environment.
“Can I help you?” a pleasant female voice asked from Jack’s right. He turned to face an immaculately dressed woman with every strand of dark hair in place. Jack was impressed. Even her manicure was perfect.
“I think so,” Jack said. He stepped over to the woman, who smiled up at him. “To be perfectly honest, I’ve never been in a chiropractor’s office.”
“Welcome,” the receptionist said. Her nametag read LYDIA.
“That’s an interesting piece of furniture,” he remarked, tilting his head toward the woman rotating and counter-rotating on the stool.
“She’s using one of our swivel chairs. It’s great for the lumbar vertebrae of the lower back,” Lydia explained. “It causes the intervertebral discs to lubricate themselves and actually swell to a degree. We encourage people to do it before their adjustment session.”
“Interesting,” Jack said. “Is Dr. Ronald Newhouse available?” He gritted his teeth after forcing himself to use the appellation “doctor.”
“He is here,” she said. She gestured toward the woman on the swivel chair. “He has his next patient at one-twenty-five. Do you have an appointment?”
“Not yet,” Jack said.
“Would you like to make one?”
“I’d like to see the doctor,” Jack said ambiguously. “I don’t know nearly as much about chiropractic therapy as I would like.”
“Dr. Newhouse is always interested in new patients. Perhaps he could see you for a few minutes before he sees Ms. Chalmers. If you don’t mind waiting for a moment, I’ll go ask him. Who may I say wishes to see him?”
“Jack Stapleton.”
“Okay, Mr. Stapleton. I’ll be back presently.”
“I appreciate your help,” Jack said. While the receptionist was out of the room, he glanced back at Ms. Chalmers as she dutifully continued her hip rotations. She had her head back, her eyes closed, and her lips slightly parted. For a moment Jack was mesmerized. She seemed to be in a trance.
“The doctor will see you now,” Lydia said, breaking Jack’s concentration. He followed her through an interior door and down a short corridor passing a series of closed doors. At an open doorway she stepped back and gestured for Jack to enter.
The office looked out on Fifth Avenue and beyond into Central Park. Inside there were two men, one sitting behind a desk, the other in a visitor’s chair. The man behind the desk, who Jack assumed was Ronald Newhouse, immediately stood up and leaned over the desk, stretching a beefy hand in Jack’s direction.
“Welcome, Mr. Stapleton,” Ronal
d Newhouse said with a salesman’s enthusiasm.
Jack allowed his hand to be vigorously pumped. Newhouse was about an inch or so taller than Jack’s six feet, and one and a half times his hundred-and-eighty-pound weight. Jack estimated he was in his mid-forties. His coloring was dark with carefully groomed eyebrows on prominent brow ridges. His eyes were dark and piercing. But the most striking aspect of the man’s appearance was his hairstyle, or, more accurately, the lack of it. His hair was medium-length, dark, and shiny, as if slathered with styling gel, but totally uncombed. Spiky clumps sprang from his scalp at odd angles.
“Meet one of my associates, Carl Fallon,” Newhouse said, gesturing toward the gentleman in the visitor’s chair.
On cue, Fallon sprang to his feet, and with alacrity that matched Newhouse’s, gave Jack’s hand a second spirited shake. “Very nice to meet you,” he said to Jack. He gathered the remains of a pastrami sandwich and a half-eaten dill pickle along with a small brown bag. “I’ll catch you later,” he said to Newhouse.
“A great guy,” Newhouse commented. He pointed to the chair Fallon had vacated. “Please, sit! I understand you are interested in chiropractic therapy. I’m happy to give you a quick intro before I see my next patient. But before I do, how did you find me? Was it through my new website? We’ve been putting a lot of effort into it, and I’m curious to know if it’s working.”
“I was referred,” Jack said. He was aware he wasn’t quite telling the truth, but he wanted to see how things would play out.
“Wonderful!” Newhouse responded smugly. “Would you mind if I asked the patient’s name? I can’t tell you how rewarding it is to get positive feedback from a satisfied patient.”
“Nichelle Barlow.”
“Ah, yes! Nichelle Barlow. A lovely young lady.”
“I’m interested to know what you as a chiropractor feel competent to treat?”
Newhouse’s smile deepened, and for a moment he seemed to be deciding where to begin. Jack focused on a series of books on the windowsill directly behind him, held upright by bright brass caduceus-shaped bookends. The titles were telling: How to Build a Million-Plus-Dollar-a-Year Chiropractor Practice and How an E-meter and Applied Kinesiology Can Double Your Practice Income. Jack had vaguely heard of e-meters, which had been described as bogus technology when a number had been confiscated by the FDA. He’d also heard of applied kinesiology, which had been discredited as having no medical value by controlled trials.